If skin traction is likely to be used for more than 24 hours, greater patient comfort and better control of the femoral fracture can be achieved by using Hamilton-Russell skin traction.

A padded sling is placed behind the slightly flexed knee and skin traction applied to the lower leg. The traction cord and pulley system is as illustrated.

The principle of the parallelogram of forces determines that the upward pull of the sling and the longitudinal pull of the skin traction create a resolution of force in the line of the femur, as illustrated.

This configuration of traction also allows control of rotation, by side-to-side adjustment of the pulley above the knee.

Complications of skeletal traction

Surgeons have moved away from skeletal traction because of multiple serious complications. These include:

Pin tract infections

Muscle wasting

Prolonged bed immobilization with resultant bed sorces

Increased resource utilization (nursing care)

Less than adequate fracture reduction

Pin tract infection - In case of pin loosening or pin tract infection, the following steps need to be taken:

Remove all involved pins and place new pins in a healthy location.

Debride the pin sites in the operating theater, using curettage and irrigation.

Take specimens for a microbiological study to guide appropriate antibiotic treatment if necessary.

Muscle wasting - A patient in traction is immobilized and a patient must be educated with physiotherapy resources to consistently perform bed exercises for all muscle groups.

Prevention of bed sores - Nursing care is the hallmark of prevention of bed sores, including regular skin checks and careful movement and attention to the posterior side of the body that is dependent.

Prolonged bed immobilization - A patient kept in bed for 12 weeks is a time consuming and expensive use of hospital resource and should only be used when there is no other option.

Poor fracture reduction - Traction provides length, but alignment and rotation is difficult to achieve accurately, often resulting in some malreduction of the femur. Late osteotomies may be needed to correct significant shortening, malalignment, or malrotation.

In the event that there is no Thomas splint available, skin traction over the end of the bed with 7 kg will be the initial treatment of a femoral fracture.

Note: With any longitudinal traction, the foot of the bed must be raised, tilting the bed, to avoid the traction weight pulling the patient down the bed.With the tilted bed the weight of the patient acts as countertraction.

Once the adhesive strip is satisfactorily in place, ensuring that the padded lower section overlies the malleoli, a spiral inelastic bandage is carefully wrapped around the limb from just above the malleoli to the top of the strip.

Preparation

Anesthesia

After painting the skin with antiseptic and draping with sterile towels, inject a bolus of local anaesthesia (5 ml of 2% lignocaine) on each side of the tibial tuberosity, into the lateral skin at the proposed site of pin insertion and medially at the anticipated exit point, infiltrating down to the periosteum.

Pin insertion

At the entry point, a stab incision is made through the skin with a pointed scalpel.

A Steinmann, or preferably a Denham pin, mounted in the T-handle, is inserted manually at a point about 2 cm dorsal to the tibial tuberosity.

As the pin is felt to penetrate the far cortex, check that the exit will coincide with the area of local anaesthetic infiltration. If not, inject additional local anaesthetic. Once the point of the pin clearly declares its exit site, make a small stab incision in the overlying skin.

Once the pin is in place, ensure that there is no tension on the skin at the entry and exit points. If there is, then a small relieving incision may be necessary.

It is important that the stirrup be freely mobile around the traction pin, to prevent rotation of the pin within the bone. Rotating pins loosen quickly and significantly increase the risk of pin track infection.

Pin site care

Various aftercare protocols to prevent pin tract infection have been established by experts worldwide. Therefore, no standard protocol for pin-site care can be stated here. Nevertheless, the following points are recommended:

The aftercare should follow the same protocol until removal of the traction.

The pin-insertion sites should be kept clean. Any crusts or exudates should be removed. The pins may be cleaned with saline and/or disinfectant solution/alcohol. The frequency of cleaning depends on the circumstances and varies from daily to weekly but should be done in moderation.

No ointments or antibiotic solutions are recommended for routine pin-site care.

Dressings are not usually necessary once wound drainage has ceased.

Pin-insertion sites need not be protected for showering or bathing with clean water.

Control of length and rotation

Length and rotation need to be checked daily.

Length is measured by comparison to the uninjured leg. Both legs are brought into comparable positions and the distances from the anterior superior iliac spines, over the knee, to the medial malleoli, are measured and compared.

Adjustment, if required, is done by increasing, or decreasing, the traction weight. Control x-rays need to be taken weekly, if possible, for at least the first 4 weeks.

If the medial/lateral angulation at the fracture site is anatomical, this line will pass over the central third of the patella.

Rotation and maintenance of dorsiflexion in the ankle can be achieved by applying an adhesive sock to the forefoot with a cord over a pulley on the Balkan beam. This pulley should be adjustable from side to side to control rotation.

With the lower half of the bed base removed and the femoral shaft fully supported by the remaining mattress, the patient starts active knee mobilization after the acute phase (7-10 days).

This comprises active extension exercises and active gravity-assisted flexion exercises, under the supervision of a physical therapist.

Once the patient can flex the knee from 0 to 90° painlessly and freely, and can actively straight-leg raise with the weights relieved, non-weight bearing mobilization on two crutches can be considered, sometimes as early as 6 weeks after the injury.

Note: Non-weight bearing involves flexion of the hip which can theoretically increase the tendency to angulate the healing fracture. Some surgeons believe that touch weight bearing, which allows the healing femur to be more vertical, is safer at this stage.

From 8 weeks onwards, progressive partial weight bearing should be started and increased to full weight bearing at +/- 12 weeks.